Lower extremity functional Scale

We are interested in knowing whether you are having any difficulty at all with the activities listed below because of your lower limb problem for which you are currently seeking attention. Please provide an answer for each activity.

Today, do you or would you have any difficulty at all with: (select one number on each line)

Name *

Name

First Name

Last Name

Phone *

Phone

(###)

###

####

Activities

A. Any of your usual work, housework or school activities. *

0 - Extreme Difficulty

1 - Quite a bit of Difficulty

2 - Moderate Difficulty

3 - A Little bit of Difficulty

4 - No Difficulty

B. Your usual hobbies, recreational or sporting activities. *

0 - Extreme Difficulty

1 - Quite a bit of Difficulty

2 - Moderate Difficulty

3 - A Little bit of Difficulty

4 - No Difficulty

C. Getting into or out of the bath. *

0 - Extreme Difficulty

1 - Quite a bit of Difficulty

2 - Moderate Difficulty

3 - A Little bit of Difficulty

4 - No Difficulty

D. Walking between rooms. *

0 - Extreme Difficulty

1 - Quite a bit of Difficulty

2 - Moderate Difficulty

3 - A Little bit of Difficulty

4 - No Difficulty

E. Putting on your shoes or socks. *

0 - Extreme Difficulty

1 - Quite a bit of Difficulty

2 - Moderate Difficulty

3 - A Little bit of Difficulty

4 - No Difficulty

F. Squatting. *

0 - Extreme Difficulty

1 - Quite a bit of Difficulty

2 - Moderate Difficulty

3 - A Little bit of Difficulty

4 - No Difficulty

G. Lifting an object, like a bag of groceries from the floor. *

0 - Extreme Difficulty

1 - Quite a bit of Difficulty

2 - Moderate Difficulty

3 - A Little bit of Difficulty

4 - No Difficulty

H. Performing light activities around your home. *

0 - Extreme Difficulty

1 - Quite a bit of Difficulty

2 - Moderate Difficulty

3 - A Little bit of Difficulty

4 - No Difficulty

I. Performing heavy activities around your home. *

0 - Extreme Difficulty

1 - Quite a bit of Difficulty

2 - Moderate Difficulty

3 - A Little bit of Difficulty

4 - No Difficulty

J. Getting into or out of a car. *

0 - Extreme Difficulty

1 - Quite a bit of Difficulty

2 - Moderate Difficulty

3 - A Little bit of Difficulty

4 - No Difficulty

K. Walking 2 blocks. *

0 - Extreme Difficulty

1 - Quite a bit of Difficulty

2 - Moderate Difficulty

3 - A Little bit of Difficulty

4 - No Difficulty

L. Walking a mile. *

0 - Extreme Difficulty

1 - Quite a bit of Difficulty

2 - Moderate Difficulty

3 - A Little bit of Difficulty

4 - No Difficulty

M. Going up or down 10 stairs (about 1 flight of stairs). *

0 - Extreme Difficulty

1 - Quite a bit of Difficulty

2 - Moderate Difficulty

3 - A Little bit of Difficulty

4 - No Difficulty

N. Standing for 1 hour. *

0 - Extreme Difficulty

1 - Quite a bit of Difficulty

2 - Moderate Difficulty

3 - A Little bit of Difficulty

4 - No Difficulty

O. Sitting for 1 hour. *

0 - Extreme Difficulty

1 - Quite a bit of Difficulty

2 - Moderate Difficulty

3 - A Little bit of Difficulty

4 - No Difficulty

P. Runnin P. Running on even ground. *

0 - Extreme Difficulty

1 - Quite a bit of Difficulty

2 - Moderate Difficulty

3 - A Little bit of Difficulty

4 - No Difficulty

Q. Running on uneven ground. *

0 - Extreme Difficulty

1 - Quite a bit of Difficulty

2 - Moderate Difficulty

3 - A Little bit of Difficulty

4 - No DifficultyOption Two

R. Making sharp turns while running fast. *

0 - Extreme Difficulty

1 - Quite a bit of Difficulty

2 - Moderate Difficulty

3 - A Little bit of Difficulty

4 - No Difficulty

S. Hopping. *

0 - Extreme Difficulty

1 - Quite a bit of Difficulty

2 - Moderate Difficulty

3 - A Little bit of Difficulty

4 - No Difficulty

T. Rolling over in bed. *

0 - Extreme Difficulty

1 - Quite a bit of Difficulty

2 - Moderate Difficulty

3 - A Little bit of Difficulty

4 - No Difficulty

Total: Please indicate the total by adding the numbers next to your selection.

Thank you!

We are interested in knowing whether you are having any difficulty at all with the activities listed below because of your upper limb problem for which you are currently seeking attention. Please provide an answer for each activity.

Today, do you or would you have any difficulty at all with: (Circle one number on each line)